PUBLIC CONCERNS / COMPLAINTS ABOUT INSTRUCTIONAL RESOURCES
RECONSIDERATION REQUEST FORM
request for reevaluation of printed or audiovisual material
Review material in its entirety before completing the following.
Fill in all applicable information
Author
_
Title _
Publisher or producer (if known)
Date of publication or production
Type of material (book, filmstrip, motion picture, etc.)
Request initiated by _
Telephone _ Address
City Zip
School(s) in which the item is used
Person making the request represents
� him/herself � group or organization
Name of Group Address of Group
1. To what in the item do you object? Please be specific; cite pages or
frames, etc.)
2. In your opinion, what harmful effects upon pupils might result from
use of this item? _
3. Do you perceive any instructional value in the use of this item? _
_
4. Should the opinion of any additional experts in the field be considered?
� Yes. Please list suggestions, if any _
_
� No.
In the place of this item, would you care to recommend other material
you consider to be of equal or superior quality for the purpose intended?
_
_
_
5. Do you wish to make an oral presentation to the Challenged Materials
committee?
� Yes (a) Please call the office of the librarian
(Telephone Number)
(b) Please be prepared at this time to indicate the approximate
length of time your presentation will require.
� No.
__
Date Signature
Adopted: date of manual adoption
PUBLIC CONCERNS / COMPLAINTS ABOUT INSTRUCTIONAL RESOURCES
RECONSIDERATION REQUEST FORM
request for reevaluation of printed or audiovisual material
Review material in its entirety before completing the following.
Fill in all applicable information
Author
_
Title
_
Publisher or producer (if known)
Date of publication or production
Type of material (book, filmstrip, motion picture, etc.)
Request initiated by
_
Telephone _ Address
City Zip
School(s) in which the item is used
Person making the request represents
� him/herself � group or organization
Name of Group Address of Group
1. To what in the item do you object? Please be specific; cite pages or
frames, etc.)
2. In your opinion, what harmful effects upon pupils might result from
use of this item?
_
3. Do you perceive any instructional value in the use of this item?
_
_
4. Should the opinion of any additional experts in the field be considered?
� Yes. Please list suggestions, if any
_
_
� No.
In the place of this item, would you care to recommend other material
you consider to be of equal or superior quality for the purpose intended?
_
_
_
5. Do you wish to make an oral presentation to the Challenged Materials
committee?
� Yes (a) Please call the office of the librarian
(Telephone Number)
(b) Please be prepared at this time to indicate the approximate
length of time your presentation will require.
� No.
__
Date Signature
Adopted: date of manual adoption